Posted
by
timothy
on Tuesday February 28, 2012 @12:33PM
from the ok-john-stick-to-the-vodka dept.

dstates writes "A recent article in in BMJ Open reports a strong association between the use of prescription sleeping pills and mortality. The study used electronic health records for 2.5 million people covered by the Geisinger Health System to find 12 thousand who had been prescribed sleeping pills and a matched set of controls. Death rates were much higher in the patients taking sleeping pills and the risk increases with age. Kudos to the authors for publishing this in an open access journal."

The people taking the medications might be dying sooner because they have insomnia which is not fixed by sleeping pills easily. The study should not compare with the general populace since they are, by definition, better sleepers than the group that isn't able to get good sleep.

Two "identical" guys one gets pill one doesn't is an anecdote.12 thousand is not just a misdiagnosis. There must be something "different" about the 12K that did vs the 12K who did not, other than random chance. I don't think in the UK treatment plans are determined using dice or tarot cards, so there must be something special about the 12K who got the pills... or the 12K who didn't...

They followed 12k users of sleeping pills, they didn't observe 12k deaths. They observed Cox hazard ratios on the order of 4/5 times, so there is unquestionably an effect; of course, now it's a correlation/causation question.

The correct next step would be a randomised trial. However, I don't see how you can ethically design a trial for this setup.

They said "matched set of controls," not "general populace." How do you know they did it wrong?

By RTFA, which I strongly advise you to do before jumping in to comment. They matched them on other factors like gender, sex, occupation etc, but not sleep trouble. Since lack of good sleep is a proven strong factor in heart disease and cancer, I feel that they did it wrong.

From the paper:
"A randomised clinical trial of sufficient duration and
size could provide definitive evidence for or against the
disturbing mortality hazards suggested by our study.
Some American NIH reviewers have opined that a randomised
trial of hypnotic lethality would be unethical. No
such trial has ever been mounted, perhaps for reasons
similar to the absence of randomised trials of cigarettes
and of skydiving without parachutes."
It is absolutely unethical to give persons with no history of sleepi

Uh, they might not have but there is a real good chance they have not got it totally right since there are so many kinds of sleeping pills to begin with not to mention not sleeping is definitely not good for you. I wonder who is behind the funding of the study. Follow the money and find the answer.

Because their results make absolutely no sense. According to the study you are more likely to die from any cause because you were prescribed sleeping pills. Therefore the act of receiving a prescription somehow increases your risk of heart disease, cancer, etc. They also state that statistically these patients did not already have disease when the experiment was begun.

Well good thing science isn't just about explaining statistics. I'm waiting for an adequate plausible explanation for the above. The fact t

According to the study you are more likely to die from any cause because you were prescribed sleeping pills. Therefore the act of receiving a prescription somehow increases your risk of heart disease, cancer, etc. They also state that statistically these patients did not already have disease when the experiment was begun.

I don't see anything that can't be explained by the simple fact that older people often have trouble sleeping, and are more likely to take sleeping pills. Ever see anyone under 50 in a So

Bingo, this is like comparing the death rates of people taking heart medications versus people who don't and then claiming the medications are killing the folks when it could be that heart disease is what is killing them and the pills are not 100% effective at all times to deal with the problem.

Also, it has been proved that bad sleep is a killer by itself, so comparing the death rates of people with sleep issues who did and who did not take medications may actually show that not taking sleeping pills might kill you if you have insomnia, which is the exact opposite of what the headline is claiming.

A matched set of controls in your example would be people with comparable heart disease who were not given the medixation. It appears that they have done that in this study:

Models addressing potential confounding of mortality association by health status
To further address the possibility that hypnotic-associated hazards were due to use of hypnotic drugs by patients with a greater burden of disease, so that elevated risks of death might be attributable to comorbidities rather than to hypnotic medications, we conducted analyses within subgroups of hypnotic non-users and users defined by diagnoses in specific disease classes (supplemental table 7). Allowing for differences in sample size, hazards in subgroups restricted to patients with specific diseases were generally consistent with the overall findings. We also observed no statistically reliable differences in death HR in subgroups constructed to assess the overall burden of disease by stratifying on the total number of comorbidities diagnosed for each patient, and no reliable differences in death HR comparing groups diagnosed with different numbers of comorbidity classes. Whereas the raw death rate of the user cohort was 4.86 times that of non-user controls (table 1), adjustment for all covariates (eg, age, gender, BMI, smoking) with stratification by comorbidities only reduced the overall HR to 4.56 (95% CI 3.95 to 5.26).

This was a not a controlled study but is a general experiment so that does raise the question of why a doctor would not prescribe sleeping pills to someone who is having a lot of trouble sleeping?

The only way to conclusively prove this would be to take patients who are going to be prescribed sleeping pills, split them into two while adjusting for other controls and have one group take the pills and other placebos and then monitor them.

that does raise the question of why a doctor would not prescribe sleeping pills to someone who is having a lot of trouble sleeping?

As is the case in many areas of medicine, different doctors will have different medical judgement about when the risks outweigh the benefits of prescription sleeping pills, when to recommend non-prescription remedies (and which remedies), and patients will vary in how the comply with and respond to non-prescripti

Whereas the raw death rate of the user cohort was 4.86 times that of non-user controls (table 1), adjustment for all covariates (eg, age, gender, BMI, smoking) with stratification by comorbidities only reduced the overall HR to 4.56 (95% CI 3.95 to 5.26).

You know what I don't see in the list of variables they controlled for? Sleep issues. It's not a matched set of controls if your experimental group is diagnosed with a serious medical condition (in this case sleep disorders) and your control group is not.

They tried to do that under the assumption that in general a lack of sleep probably doesn't kill you. The hypertension, or diabetes, or heart disease, or liver failure or obesity is that kills you. They did control for differences in those factors and found no change in their results.

Of course, the increased rate of crashing your car into to a wall at 90mph due to insomnia wouldn't be taken into account.

The comparison is done using "specific disease classes". It does not rule out an unknown or undiagnosed illness in the patients that are causing them to use, misuse or abuse sleeping pills. The statistics can only be adjusted for known diagnosed illnesses.

It also does not deal with the issue of people who use sleeping pills responsably; ie not often and only for a couple of nights at a time. Perhaps it is the chronic pill poppers whi are dieing and maybe there is an underlying reason for the insomnia that i

Because of course you know this but the researchers doing the work didn't hink of that because they are idiots?

So which part of their methodology specifically do you have a problem with, given you must have checked it before spouting off, right?

Here you go, here's some of the methodology paragraphs from the linked article, though of course you also read the supplementary material to I hope (slashdot doesn't like some of the fancy characters like +/-):

The problem is the factors that bring people to diet soda are overweight or diabetes which are both factors that would tend to increase risk of heart desease. Here too the people that are prescribed sleeping pills are a self selected group on some problem associated with sleep. They can say they have factored in all the external variables but that may not be that case or there may be other factors related to sleep problems that are more to blame and this study would not be complete or accurate unless it followed an equally large group of people that would have been given sleeping pills but were not and/or given a placebo, You don't know if giving a pill is the problem say vs not giving a pill as one factor. If you give a placebo you don't test that variable.

The study said it matched "matched controls with no hypnotic prescriptions" but they did not match with those who would have been prescribed meds but weren't. You may only be seeing the effect of the problems they had. I could be that the meds actually lengthened life vs the group not given them. This is the problem with vacines that have side effects, but the cure in general is much better for society than the side effects.

But that kind of study is hard to come by so you may just have to go on the data you have but as in religion and politics attribution can be a grand evil.

That is the point of the controls."Correlation != Causation" is used when you find a statistical trend in a group.But if you take a group and have some of that group be the controls (identical except for one variable) then you cannot say that.You could find a flaw in their control method, but simply saying "Correlation != Causation" is idiotic in all situations like this.

Those were not controls. They were simply a group matched on a very few parameters. Not everything. Not nearly everything relevant.

A control would have been to take people diagnosed exactly the same and giving some sleeping pills and the others placebos. That didn't happen. The sleeping pill group might have all had a family history of sleep apnea which was not diagnosed before giving the pills. We don't know because there was no randomization.

That's what they're claiming. Just because it's not the cause, doesn't mean it's not useful to know. Your theory about insomnia certainly isn't one that the researchers are unaware of. They're collecting data as they should be.

I'm tired of seeing these stupid comments every time an article on statistics is brought up. Clearly, a bunch of scientists doing studies along these lines know less about statistics and research design than some random Slashdot poster. Gee. Get over yourself.

I'm tired of seeing these stupid comments every time an article on statistics is brought up. Clearly, a bunch of scientists doing studies along these lines know less about statistics and research design than some random Slashdot poster. Gee. Get over yourself.

But in just this situation, academics in neuroscience papers routinely claim to have found a difference in response, in every field imaginable, with all kinds of stimuli and interventions: comparing younger versus older participants; in patients against normal volunteers; between different brain areas; and so on.

How often? Nieuwenhuis looked at 513 papers published in five prestigious neuroscience journals over two years. In half the 157 studies where this error could have been made, it was. They broadened their search to 120 cellular and molecular articles in Nature Neuroscience, during 2009 and 2010: they found 25 studies committing this fallacy, and not one single paper analysed differences in effect sizes correctly.

These errors are appearing throughout the most prestigious journals for the field of neuroscience. How can we explain that? Analysing data correctly, to identify a "difference in differences", is a little tricksy, so thinking generously, we might suggest that researchers worry it's too longwinded for a paper, or too difficult for readers. Alternatively, less generously, we might decide it's too tricky for the researchers themselves.

Why is it wrong for a Slashdot poster to have a conversation over the statistics involved when the headline is so sensationalist? What if someone reading stops taking sleeping pills that are helping them sleep and then get needlessly killed by insomnia because of bad statistics? Can't there atleast be a discussion on the statistics used?

I am tired of seeing stupid comments like yours that actually don't refute anything and instead attack the poster and call scientists infallible and above question.

He has a point... if you actually read the article the authors specifically pointed this out already. Clearly they understand the usual trite statistics adage, but that doesn't mean the study wasn't interesting.

Cohort studies demonstrating association do not necessarily imply causality, but the preferable randomised controlled trial method for assessing hypnotic risks may be impractical due to ethical and funding limitations.

Which IMO kind of makes the title of your comment almost as sensationalist/mislead

Having had insomnia and tackled it one time around with sleeping pills and another time around by kicking energy drinks, caffeine, sugars, and artificial additives to the curb and integrating healthy food and teas, I can tell you there's a difference.

Like most anything that leads to trading on Wall Street, sleeping pills are about making money off of your ailments, not bettering your health.

What may be showing in this study (if it has any merit at all) is that chemically induced sleep may not provide enough "rest" to be useful.I know of one person with a sleep problem that does not like taking sleep meds because its a express ticket to Nightmares on the level of "Pinhead looks Like Reverend Fred McFeely Rogers".

So i would (just dartboarding ideas) do a study where

1 Control Group (does nothing special)2-N Meds Group (takes different meds)N+1 Sound Group (listens to different sounds may need to

How often is healthcare data used for these sorts of studies? Not that I have a problem with it, quite the opposite, so long as the data is sanitized. To me it makes more sense to data mine existing records than set up and conduct expensive studies, am I missing something or is this actually commonly done?

They're called "statistical studies" and they are used as evidence that a real study should be done, not that there's an actual effect in play. The problem with such studies is that they try their best to select an identical control group, but it's hard to do so. In this case it means matching the 15,000 people on the drug with 15,000 people who also have been diagnosed with insomnia (and for similar reasons), but all elected not to be medicated for it. Then you hope that that decision isn't in any way correlated with other behaviors that might increase or decrease the death rate.

Taking pills to help/force you to fall asleep on a consistent basis can't be good for you. That said, neither can not sleeping on a consistent basis. Even with the risks in mind, I imagine in many cases it still makes sense to keep taking the pills?

I quit smoking because I don't want to get cancer, and I don't want to smell bad all the time, and I don't want to be out of breath walking up the stairs. That said, I loved smoking. I still miss it every day, but the risks are greater than the rewards.

Stop taking my sleeping pills? Hah. Have you ever been so tired that you get a sore throat? Or that you argue with yourself at a stop light, "no, don't close your eyes, I know it would feel really really good but if you do that you'll miss the green and might not wake up until somebody knocks on your window"? Your legs shake, you feel sick to your stomach, your palms sweat constantly, your eyes try to close with all their might until you can hear the muscles straining in your ears.

Now try feeling like that for months on end. Stop taking my sleeping pills? Fuck that shit, I'd rather die early.

Or that you argue with yourself at a stop light, "no, don't close your eyes, I know it would feel really really good but if you do that you'll miss the green and might not wake up until somebody knocks on your window"?

Drug companies spend more on marketing than they spend on research. Is it any surprise that these stories keep coming up? SSRIs were going to cure everyone's depression. Now we find out that they're addictive, and only effective in the very worst cases of depression. Vioxx was going to usher in a new age of pain relief for arthritis, turns out it killed tens of thousands of people. Hormone replacement therapy was considered essential to prevent osteoporosis in women. Turns out it also causes bone remodeling that makes certain types of fractures even more common. Don't be surprised if we find out in the future that wonder drugs like statins carry risks we haven't been made aware of.

Pharmaceutical companies should not be allowed to market. Not to the general public, and not to doctors either.

Death is also correlated with use of statin drugs, a rather poor outcome for the patient if you ask me. There have been major studies on this, and takiing statins results in more deaths during the study period, but fewer deaths due to heart attacks. Big deal, dead is still a negative outcome in a drug study.

I personally consider the huge number of prescriptions for statins to be malpractice. If drug-induced cholesterol lowing was effective in treating hyperlipidemia, why did not the non-statin drugs that l

I talked to a 60-something woman who used to have extreme fibromyalgia problems last weekend. Estrogen came up, and she said her doctors had put her on it years ago. She was in the hospital within a week.

... but it also prevents new bone from growing. Progesterone - the natural kind (progesterone USP), NOT the kind in birth control (Provera) that was studied in the Women's Health Initiative - is what helps new bone get laid down.

Progesterone is good on all counts. It's a hormone on its own, and the body converts it into other hormones, like testosterone and cortisol. This is why birth control [teslabox.com] takes away women's libido - fake progesterone ("progestins") CANNOT be converted into other hormones, which leads t

A recent post to/. pointed to several articles that brought up the fact that a solid 8 hours of sleep may not be normal.http://www.bbc.co.uk/news/magazine-16964783http://en.wikipedia.org/wiki/Segmented_sleephttp://www.history.vt.edu/Ekirch/sleepcommentary.htmlhttp://www.nytimes.com/2006/02/19/opinion/19ekirch.htmlOur brains may very well be wired to a distrupted sleep and taking pills to 'correct' this is not a good idea!

"Cohort studies demonstrating association do not necessarily imply causality, but the preferable randomised controlled trial method for assessing hypnotic risks may be impractical due to ethical and funding limitations."

It's well-known that sleep disturbances are correlated with higher mortality. This study could simply be uncovering that people who have sleep disturbances (and who are therefore in a higher mortality group) are more likely to ask for meds to help them sleep. Can't see that there's any big news here.

I just lived through six years of chronic insomnia and went down the whole path of doctors and pills. What it turned out to be was a undiagnosed heart arrhythmia caused by a untreated infection which was exasperated by fluroquinalone which almost killed me. It just shows that Doctors just collect a paycheck and push what ever pills big pharma claims works.( it took 6 years and about $300,000 in medical bills and completely wiped out my financials and credit) After getting on propafenone for the arrhythmia f

My own 0.02 suggests that Big Pharma probably isn't completely blind to some of the problems behind sleeping medications. Addiction side effects no withstanding, there are thoughts that these medications could have diliterious effects on the brain's neurochemistry. The trouble with Big Pharma is that it has little or no interest in curing disease because there is no profit in it. The profit is in long term symptom mitigation and sleep medications are simply just that - mitigations. Sleep needs to be mor

You know I track this stuff as my father died of cancer, so I am rather keenly aware when new cancer treatments pop up.

However, over the past 2 years I have noticed a trend that just about every major medication from cholsterol pills, to sexual disfunction to vaccines, have 3-5 times the elevated risk factors for people to die of cancer.

If I didn't know any better the industry is astroturfing for patients to increase profits.

Most of the people I know who take sleeping pills are not necessarily the most stable people in the world to begin with. Sorry to all you Ambien fans.

Theoretically, yes. In practice I don't think so.

This 'confounding by indication' is one of the biggest problems in pharmacoepidemiology. We know that people take meds because there is something wrong with them. We also suspect that taking certain meds over a long period of time is bad for you, particularly if you are already at high risk. So how can you separate those effects? A lot of statisticians spend a lot of time thinking about this, and 'adjusting for everything you can think of', propensity scoring and very tight matching of cases and controls seem to be the most often used solutions. None of these is satisfactory as they obviously don't adjust for things you can't measure. Use of instrumental variables is another possibility but there is rarely a good instrument to use.

Ideally you would run a randomised trial of a med to check whether death rates or adverse drug reactions are higher in the group taking them, but this is impractical because often the required trial would be enormous (massively expensive and time consuming), would have to recruit many of the 'high risk' people that are the groups most at risk of excess mortality but are usually not recruited into trials, and could only really examine one compound at a time. Also trials exclude people taking many other medications, or with comorbid medical conditions, because these may be unsafe and would again dilute the true effects - however it is likely that unknown drug-drug interactions are the cause of a lot of the problems we think we are seeing.

It's easy to snipe at this kind of research since its 'correlation not causation' but this really is the best that is possible at the moment when trying to answer these extremely important questions regarding drug safety. If anybody has any better ideas we'd be glad to hear them.

None of these is satisfactory as they obviously don't adjust for things you can't measure

Or things you won't measure for whatever convoluted reason.

For example, back pain patients given powerful painkillers recover slower or not at all compared to no painkillers.

Example of false reasoning: I overstrained my back doing some overambitious carpentry alone. Intense pain when sitting or standing, laying on back not so bad. Went to doc, did not accept script for painkillers because I slept on my back just fine and everything I do sitting or standing is not allowed while on pain killers anyway (can't even drive to work if I'm high on painkillers). Also doc is all nervous that I'm dr shopping for abuse meds and really chilled out and got more helpful once he realized it was perfectly clear that I was only genuinely trying to fix my back. blah blah blah. The point is the diagnosis of "back pain" is the same for me and someone who's in agony even when lying down so they need painkillers just to sleep. No great stretch of imagination that the guy in more agony than myself is more F'd up and takes longer to recover (took me only about half a week, but I've heard if you really F up your back it can be semi-permanent, months maybe). Multiply this by 15K and you get a whopper like "taking painkillers means it takes months to recover from back pain diagnosis instead of days"

I couldn't find anything in it to suggest they had actually done a double-blind trial, or even a half-assed blind trial, so their results are purely correlation, and not causation, despite the time they spent talking about causation. They do suggest that 'hangovers' from the drugs are a cause of traffic accidents and such, though, so they at least thought of that.

The patients did not know they were being monitored (blind.) The doctors/nurses who entered the charts didn't know their patients' data would be used for this research (double-blind.)
The people who analyzed the data, however, had everything upfront to poll and draw whatever conclusions they were looking for. "Using a query into the EHR..." "A further query of this subset..." "For each hypnotic user, we attempted to identify two controls with no record of a hypnotic prescription..." Sounds like they need a triple-blind experimental design.

Sounds to me like data mining and meta analysis, which is all the rage today.

This study followed their subjects for an average of ONLY 2.5years. They clearly didn't follow them prior to the prescriptions.Further the "controls" were selected based on superficial categories (age, gender, smoking, body mass index, ethnicity, marital status, alcohol use and prior cancer). Nowhere near a complete list of things that keep people awake at night.

And the causation argument still is the key here, since these drugs (several common hypnotics, including zolpidem, temazepam, eszopiclone, zaleplon, other benzodiazepines, barbiturates and sedative antihistamines) are not usually prescribed for people who have no problem sleeping.

Selection of controls was really the weak point here.

If you are under enough stress, or have some other problem keeping you awake, its as likely those issues are to blame as the use of these drugs. The headlines could just as well have been "Trouble Sleeping may be Killing you".

This is not really true. The purpose of a double-blind experiment is to set up a study with a controlled variable and observe the outcome. This is a meta-analysis, which looks at previously gathered data and tries to see if there are interesting patterns. The problem with such analysis is that although "blind" in the sense that it does not influence results, it is not "blind" in the choice of data. Whether intentionally or not, by cherry-picking data it is easy to create associations where none exist. This is further biased by the fact that only positive results are reported - no one writes of all the "no correlation" results they may have found through different choices of matched sets.

For example, I am sure that I could take a piece of data such as daily temperature and pick a subset of the stock market that happened to correlate with it - something that is likely entirely a figment of the data sets. This is the danger in such studies and it explains why they are NOT in any way the same as a double-blind trial.

"This is further biased by the fact that only positive results are reported - no one writes of all the "no correlation" results they may have found through different choices of matched sets."

If you're honest with your stats you multiply your p-value by the number of comparisons you did. Yes, some of us do this. There's nothing wrong with retrospective analyses, it's just that so many people do the stats incorrectly.

this is called "multiple testing," and is an instance of what is derogatorily called "data-dredging" (as opposed to data-mining, which is (hopefully) doing this sort of thing responsibly). there are ways to do multiple testing correctly.

for instance, you can sometimes test whether there is any effect and then, if that is positive, go into identification. if nothing else, you can do a bonferroni correction, which is dead simple and almost always valid, but also overly stringent (it multiples p-values by the

No. When you do an experiment, i.e. purposely manipulate one variable, you establish a causal connection. Identifying and explaining the mechanism is nice, and establishes the character and directness of your causal relationship. Trials are experiments.

Correlation comes from observational studies where you do not manipulate any variables yourself, you just look for natural or preexisting variation.

A simplified example - if I look at a bunch of people who take sleeping pills and a bunch who don't, and measure how likely they are to die, I get a correlation (maybe) - dying and taking sleeping pills are correlated, but I don't know if dying causes people to take sleeping pills, whether sleeping pills tend to cause you to die, or whether some other factor (being crazy maybe) causes you to both take sleeping pills and die.

If I take a bunch of random people and give some sleeping pills and others no sleeping pills, if the ones I give the pills die significantly more often then I can conclude that sleeping pills cause death (by some mechanism I don't yet know).

Most people taking prescription sleeping pills have been fighting sleep disorders for a long time, probably their entire adult lives. Getting terrible sleep for 30 or 40 years will probably increase your mortality regardless of what pills you're taking. Do the same study again only this time instead of looking at what drugs they're on, give them a sleep disorder questionnaire, drowsiness survey, and a sleep study. Then you'll have enough data that I actually care to look at your results.

Yeah I had been having troubles sleeping since I was a kid and finally in the fall went to a sleep doctor. She set me up with a sleep study and found that as well as not sleeping long enough(had problems with my ceridian sleep schedule) I also had sleep apnea. I got CPAP and took some meletonin for a few months and man that was a crazy difference. It's like I had never had a good nights sleep in 20 years and all of the sudden you feel more energetic, awake and coherent.

There's no shortage of people(myself included) who don't sleep very much. A good night over the last two years for me would be 3 hours of straight sleep. Though the last week I've been sleeping 8-9 hours without a problem, mostly because I've started a new mix of pain killers and muscle relaxants.. It can be from a variety of problems though, but if they put up a request for volunteers to fill out info, they'd find them.

"The population is mostly of low socio-economic status, having less than high school education and less than one-third are insured under the Geisinger Health Plan."

"We were unable to control for depression, anxiety and other emotional factors because of Pennsylvania laws protecting the confidentiality of these diagnoses."

The results of this study ought to be interpreted in light both of the socio-economics, demographics, and regional characteristics of the population studied, and of the potentially crucial categories of comorbidity that were excluded.

My own use of zolpidem (Ambien) was during a time of an extraordinary convergence of situational stress factors. Once the stress conditions resolved, I was able to discontinue the drug.

You could have answered that with a simple act of RTFA. In short: no. They had no access to their subjects' mental health records.

I put up my screed on the weakness of the study (after seeing it covered by the Grauniad) at http://tmblr.co/ZaUL7yHBNSh0 [tmblr.co] before I saw it here, and the short version of my unassailable opinion is that it is a deeply flawed study whose data is just good enough to make a strong case for further study, undermined by the authors drawing unsupportable conclusions and pointlessly denigrating prior work and practical experience.

And yes, hypnotics are often taken by people for whom insomnia is a secondary condition grounded in deeper problems. That doesn't mean the hypnotics are not very useful in enabling them to address the deeper problems. Speaking from personal experience, a dozen doses of Ambien taken over the space of about 2 months during the breakup of my first marriage were critical to saving my job, my ability to eventually pull out of a deep depression, and possibly as many as 4 lives. When life is slicing deep enough that you cannot sleep for days on end, the lack of sleep itself gnaws on the stripped bones of sanity.

The main recommended use of hypnotics is for short periods in cases where insomnia itself is causing additional problems and more comprehensive treatments for underlying primary causes are too slow and/or are impeded by the effects of insomnia. Real primary insomnia that can be managed with hypnotics is pretty rare. A valid conclusion from the study is that people in that one HMO in rural PA who are being prescribed hypnotics are not getting adequate overall care, and that the inadequacy correlates with the amount of hypnotics that they are being prescribed. The authors claim (and I tend to believe them) that there is a growing consensus that CBT is a better treatment for chronic insomnia, but CBT is not something a doctor can write a scrip for and have the patient sleeping soundly that night for a few bucks. It can also uncover and address underlying issues like depression, OCD, and other cases where insomnia is really just a symptom of a more complex primary mental disorder. Of course, if you are a researcher specializing in retrospective studies of this sort who has been given access to a very large data set of patient records by an HMO, you don't have a strong incentive to write a conclusion that this HMO is controlling costs by encouraging doctors to prescribe cheap drugs instead of referring patients to expensive months-long rounds of a talk therapy, even when the best type seems to be the relatively efficient CBT.

#1 has been my experience as well. I have a few friends who mention having constant problems sleeping. They're also the most inactive and eat like hell. Inactive to the point of refusing anything that might cause activity.:/

Sure, cardio isn't necessarily as fun as playing Xbox but sleeping awesome is totally worth it. I "trick" myself into exercising by just picking up a sport and sticking with it. Treadmills are boring, but sport can be fun with the right crowd.

I "trick" myself into exercising by just picking up a sport and sticking with it. Treadmills are boring, but sport can be fun with the right crowd.

Nailed it on the head.

Back when I embarked on getting into better shape.. I struggled to force myself to do the recommended weekly exercise. It was 30 minutes I really would rather spend doing something else. Then I got into a floor hockey thing some guys at work had going and it literally changed everything. I saw the light. Not only was I getting way more exercise than I was doing jumping jacks in my basement.. but I actually _looked forward_ to it.

There's no need to shill for a specific brand. I don't know what's in your selection Anything with chamomile in it will tend to make you sleepy unless it's counterbalanced by some other herb. YMMV. Chamomile works for me. I'm sure there are plenty of people who have a cup and it does nothing. Perhaps there are even people kept up by it. I know that some people can be kept up by sleeping pills because they're nervous about what the pill might do. I'm sure herbs are no different.

Isn't that the entire reason to "shill" for a specific brand? He has a specific brand that works for him so that's what he's recommending. He doesn't know what's in every "sleepy time" tea on the market, and probably doesn't even know what's in his specific brand of tea that makes him sleepy, all he knows is that it works. For him.

I strongly suspect a lot of people with chronic pain issues are on some kind of sleeping pills.

The types of pills in the study - hypnotics - don't really help when you're in pain. Of course, they would if you mixed them with strong pain-killers, but then you'd have the possibly of actually dying (dieing?) in your sleep...

Did you consider: Even if this study is flawed, it might do something about the approach of providing benzos to people who have trouble sleeping. Maybe the actual reason why they aren't sleeping will be investigated. It's probably something completely treatable: overstress, uncontrolled diabetes, nutritional deficiencies, abuse of some other substance like caffeine, etc.

Melatonin is fine and I highly recommend its use, opposed to traditional sleep aids (I use it). Melatonin is a sleep aid, in that it aids you in falling asleep... but it is different from traditional (prescription) sleep aids such as Ambien, in that it is a hormone supplement.

Melatonin is a non-benzodiazepine, while traditional sleep aids are benzodiazepines. Melatonin (N-acetyl-5 methoxytryptamine) is a compound naturally created in the pineal gland of the brain which triggers sleep. This should not be confused with the feeling of being tired, depleted of energy, or "heavy eyes." Traditional sleep aids act more like an anesthetic, actually making you feel tired and/or knocking you out.

Melatonin is non-habit forming, nor does the body develop tolerances for it, as in drugs like Ambien. It's kind of like a "passive" sleep aid, while Ambien/Benadryl/Lunesta/etc would be "active" sleep aids. There's a reason why it is available over-the-counter.

Note- while you can get Melatonin over-the-counter, you'll likely find nothing higher than 1mg doses (sometimes up to 3mg). You CAN, however, get a prescription for it. Then you can get a higher dose (up to 5mg?), in larger quantities (bottle of 40 as opposed to over-the-counter pack of 14ish), and your insurance will likely cover it.Warning- with higher doses, especially if your body is already producing it's own, it may take a while for your body to expel the excess in the morning. This could make you feel groggy, make it hard to wake up, and make it too easy for you to fall back asleep (i.e. while driving). Take it 20-60min before sleep, sleep for at least 8 hours, give yourself 20-60min to wake up before driving.

I showed your post to an MD, who said that while everything you asserted is more or less true, what you failed to assert far outweighs the value of the information you did provide. Melatonin has documented negative interactions with Coumadin, Warfarin, and Aspirin, which are widely prescribed anti-coagulants. Melatonin will also nullify the effects of any corticosteriods you happen to be on. So -- do us all a favor, eh, and don't leave off the bad parts just because you are a fanboi of the good parts.

The stats are for Zolpidem and Temazepam, drugs which have a high therapeutic index ration, in other words, several time a one month supply, which is all that a pharmacy is allowed to dispense at the same time. I highly doubt anyone is using these drugs to kill themselves.